Video-assisted thoracoscopic (VAT) lobectomy is demonstrated to be safe and effective. Its adoption rates are low. Less than 10% minimally invasive out of 28 771 lobectomies in a recent study from the European Society of Thoracic Surgeons might reflect difficulty in acquiring appropriate skills, but other reasons are expected.
Keywords: VATS, lobectomy, Germany
Materials and Methods
A retrospective review of a database (2011-2016) at a German lung clinic was performed to identify patients undergoing potentially curative lobectomy for NSCLC. Case control (age, gender, ASA status) was performed (1:8) to obtain a balanced cohort of patients undergoing VAT and thoracotomy lobectomy. Data were collected retrospectively on 33 consecutive VAT lobectomies patients it was compared to 33 thoracotomy lobectomies patients in terms of length of stay (LOS), length of thoracic drainage (LTD) and pain visual assessment score (VAS). Retrieved data was compared with historical data from a Slovenian clinic. All VAT lobectomies in the study were performed by the same consultant thoracic surgeon.
24 males and 9 females underwent 6 right upper, 1 middle, 8 right lower, 6 left upper, 8 left lower lobectomies, and 4 segmentectomies. All patients in the study had primary lung cancer. 17 were T1 and 16 were T2 lesions. Three patients had positive nodes at postoperative examination, giving N status as follows: 22 N0, 9 N1, and 2 N2. Operating time for the series averaged 141 minutes. There was no surgical mortality and no transfusion. Procedures converted to open thoracotomy (4 patients) were excluded from the study.
Average LTD was 5 days, average LOS after surgery was 12 days for the observed group. Data was compared to case control group of patients after thoracotomy and lobectomy. Thoracotomy group had statistically significant longer times for LTD 11 days (p=0,002) and LOS 17 days (p=0,005). Average maximal VAS score was lower in the VAT lobectomy group (p=0,008).
Introducing a VAT lobectomy programme was associated with a significant reduction in LTD and LOS. It is a technically feasible and safe procedure with reduced intraoperative blood loss, morbidity or mortality when compared to thoracotomy lobectomy. Removing the chest tube additionally reduced the VAS score in VAT lobectomy group. Such a correlation was not so apparent in the post thoracotomy group of patients.
LTD and especially the LOS were significantly longer than those in the comparable studies or those from historical group of patients operated on in Slovenia. German health care and insurance system is still based on overall LOS. Thereby a shorter LOS would cause a cut into the reimbursement.
VAT lobectomy is a good technique to address the ever ageing population, it was well accepted by patients, referring physicians and hospital staff. The technique was associated with reduced postoperative pain, the chest tube management being the limiting factor at the time. The extended LOS at the clinic was used for postoperative early rehabilitation and was well accepted by the patients. However longer LTD compared to other similar data and historical patient cohort from Slovenia did not reduce the number of readmission of patients due to postoperative pleural effusion. Further implementation and acceptance of this technique is needed also in developed healthcare systems.
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